OPG Imaging - Montgomery Dental Care

Clinical justification: In accordance with IR(ME)R 2000 a clinical justification must be provided for each dental OPG.

Reporting: All reporting for the requested images is to be carried out by referring clinician as required by IR(ME)R 2000/2006

Payment: Who is responsible for payment?

Patient at appointment Invoice referring practitioner

I confirm that the patient has given consent to be contacted by Montgomery Dental Care

Via telephone Via telephone & letter Via telephone, letter & email

I confirm that the patient has given consent to be contacted by Montgomery Dental Care

Via telephone Via telephone & letter Via telephone, letter & email

I certify that the information provided on this referral form is accurate to the best of my knowledge, and that the patient has consented to onward referral for the provision of specialist treatment/services from Montgomery Dental Care

Yes No

Acceptance

Montgomery Dental Referral Declaration By submitting this referral, I authorise Montgomery Dental to undertake an OPG scan on behalf of my patient. The completed OPG image will be provided electronically via secure email or disc. I acknowledge that responsibility for reviewing, interpreting, and acting upon the radiographic findings remains with the referring clinician. This includes assessing the suitability of treatment, identifying any abnormalities or pathology, and arranging onward referral to the appropriate specialist services where clinically required. Montgomery Dental and the radiographic operator are not responsible for diagnosis, treatment planning, or referral decisions arising from the scan. I understand that current radiography guidance recommends that all clinicians referring patients for OPG imaging should hold appropriate radiology training and competency. By making this referral, I confirm that I have the necessary qualifications and experience to evaluate the radiographic information provided, or that I will arrange for assessment by a suitably qualified Consultant Radiologist where appropriate.

OPG Imaging Request

MONTGOMERY DENTAL CARE

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